Performance Tracker 2022: Adult social care

Covid has hit adult social care services hard. In 2020/21, some 39,000 people in residential and nursing homes died from the virus, ²⁴¹ Care Quality Commission, ‘Publication of statistics on deaths involving COVID-19 in care homes in England: transparency statement’, 12 May 2022, retrieved 28 September 2022, www.cqc.org.uk/publications/major-reports/publication-statistics-deaths-involving-covid-19-care-homes-england discouraging older people from coming forward for care. ²⁴² Bottery S, ‘How Covid-19 has magnified some of social care’s key problems’, The King’s Fund, 25 August 2020, retrieved 28 September 2022, www.kingsfund.org.uk/publications/covid-19-magnified-social-care-problems By the end of 2020/21, both the number of people in long-term nursing and residential care and the number of requests for this care had declined. But there is some indication that demand for care did not go away permanently: 2021/22 saw an increase in the number of people awaiting assessment for care.

At the same time, the workforce crisis that briefly eased during the first year of the pandemic is now worse than ever, with 50,000 fewer posts in the social care workforce filled in March 2022 than at the same point the year before, and the highest vacancy rate on record. This has severe implications for providers’ ability to operate effectively. Directors of adult social services report more providers going out of business or handing contracts back, unable to provide enough care to meet demand. This has ripple effects across public services, particularly hospitals and general practice.

The cost of care is also rising, with providers facing a range of inflationary pressures. Central government provided a large package of grants during the first two years of the pandemic, but that support has ended. It is now up to providers and local authorities to meet any funding shortfalls. Where this money will come from is unclear.

Covid-related spending on adult social care totalled £5.3bn over the first two years of the pandemic

Local authority Covid-related spending on adult social care amounted to £5.3 billion over 2020/21 and 2021/22, with spending falling from £3.2bn in 2020/21 to £2.2bn in 2021/22. Spending on workforce pressures was the only category to increase over the same time period, rising from £231.6 million to £282m, an increase that reflects worsening workforce retention in the second year of the pandemic, discussed further below. This money was spent on a range of initiatives such as supporting payments to increase hours worked, local recruitment initiatives and the hiring of local authority social services staff. ²⁴³ Department of Health and Social Care, ‘Workforce Recruitment and Retention Fund for adult social care’, 27 April 2022, retrieved 16 September 2022, www.gov.uk/government/publications/workforce-recruitment-and-retention-fund-for-adult-social-care/workforce-recruitment-and-retention-fund-for-adult-…

Spending on ‘supporting the market’ – money to prevent providers going out of business – made up the largest proportion of spending in both years, at 39.5% and 39% respectively. The Care Quality Commission (CQC) found that this funding largely achieved its intended purpose, with fewer-than-expected providers closing or handing contracts back as a result of support funding. ²⁴⁴ Care Quality Commission, ‘Adult social care fragility’, 12 May 2022, retrieved 28 September 2022, www.cqc.org.uk/publications/major-reports/soc202021_02g_asc-fragility But it also found that some providers benefited more than others from emergency funding, with home care providers in particular seeing “stable or improved profit margins over the course of 2020/21”. ²⁴⁵ Ibid. The end of this funding in March 2022 raises questions about market sustainability, as discussed below.

Grants from central government mostly funded the additional spending. This money was provided as a mixture of un-ringfenced grants that could be spent at the discretion of local authorities and grants intended for specific purposes. ²⁴⁶ Brien P, ‘Covid-19: search funding for local authorities in England’, House of Commons Library, 2 February 2022, retrieved 28 September 2022, https://commonslibrary.parliament.uk/covid-19-search-funding-for-local-authorities-in-england For adult social care, the latter category included grants such as the adult social care Infection Control Fund (worth £2.1bn over 2020/21 and 2021/22), ^{247 Department of Health and Social Care, ‘Adult Social Care Infection Control Fund – round 2: guidance’, 1 July 2022, retrieved 15 July 2022, www.gov.uk/government/publications/adult-social-care-infection-control-fund-round-2/adult-social-care-infection-control-fund-round-2-guidance   248 Department for Levelling Up, Housing and Communities, ‘Coronavirus (COVID-19): emergency funding for local government in 2020 to 2021 and additional support in 2021 to 2022’, 30 March 2020, retrieved 12 May 2022, www.gov.uk/government/publications/covid-19-emergency-funding-for-local-government} the Workforce Capacity Fund for adult social care (£120m in 2020/21) ²⁴⁹ Department of Health and Social Care, ‘Workforce Capacity Fund for adult social care’, 3 November 2021, retrieved 22 August 2022, www.gov.uk/government/publications/workforce-capacity-fund-for-adult-social-care/workforce-capacity-fund-for-adult-social-care and the Workforce Recruitment and Retention Fund for adult social care (£462m in 2021/22). ²⁵⁰ Department for Levelling Up, Housing and Communities, ‘Coronavirus (COVID-19): emergency funding for local government in 2020 to 2021 and additional support in 2021 to 2022’, 30 March 2020, retrieved 12 May 2022, www.gov.uk/government/publications/covid-19-emergency-funding-for-local-government

Central government support has driven spending increases during the pandemic

The amount the government spent on adult social care increased by 7.4% in real terms between 2019/20 and 2020/21 (and by 8.1% between 2009/10 and 2020/21). The majority of this increase came from additional local authority spending on adult social care, financed mostly by central government grants that were designed to support both social care users and providers during the pandemic. ²⁵¹ Local Government Association and Association of Directors of Adult Social Services, ‘Temporary funding for adult social care providers during the Covid-19 crisis’, (no date), https://local.gov.uk/sites/default/files/documents/Provider%20fees%20-%20summary%20of%20the%20approach%20proposed%20by%20local%20%20government%20-%20… This additional spending amounted to £3.2bn of the £20.7bn spent on adult social care in 2020/21. This was an overestimate of the additional adult social care costs that local authorities would incur during the pandemic and, as a result, councils spent less of their core funding on care than in the previous year. This was not necessarily intentional, but instead a result of rolling forward previous forecasts due to a lack of available data. ²⁵² Institute for Government interview. This overestimation – along with similarly pessimistic forecasting in other local authority-provided services – resulted in local authorities increasing their usable reserves in 2020/21, despite Covid pressures. ²⁵³ Ogden K and Philips D, Looking back to look forwards: what can we learn from data on the impact of COVID-19 on councils in 2020-21?, Institute for Fiscal Studies, 11 January 2022, retrieved 28 September 2022, https://ifs.org.uk/publications/looking-back-look-forwards-what-can-we-learn-data-impacts-covid-19-councils-2020-21

Adult social care spending was budgeted to be 0.4% lower in 2021/22 in real terms than the actual spend of £20.7bn in 2020/21, although this would still represent an increase of 5.4% in real terms, compared with 2019/20. This level of spending is unlikely to be sustainable, given the pressures on adult social care, with evidence that even the current level of funding is not enough to meet existing pressures. ²⁵⁴ House of Commons Levelling Up, Housing and Communities Committee, Long-term Funding of Adult Social Care: Second report of session 2022–23 (HC 19), The Stationery Office, 18 July 2022, p. 3, retrieved 28 September 2022, https://committees.parliament.uk/publications/23319/documents/170008/default

Reduced support and rising costs will put pressure on local authority and provider finances

Central government emergency Covid support to local authorities ended in March 2022, ²⁵⁵ Association of Directors of Adult Social Services, Spring Budget Survey 2022, 19 July 2022, p. 19, www.adass.org.uk/media/9390/adass-spring-budget-survey-2022-pdf-final-no-embargo.pdf although Covid pressures persist in adult social care. While not as burdensome as during the first two years of the pandemic, there is still a need for increased infection prevention and control, although it is difficult to estimate how much this costs providers. ^{256 Institute for Government interview.   257 Omar I and Rocks S, ‘What will it cost to get the NHS and social care on the road to recovery?’, The Health Foundation, 2 September 2021, retrieved 28 September 2022, www.health.org.uk/news-and-comment/blogs/what-will-it-cost-to-get-the-nhs-and-social-care-on-the-road-to-recovery}

The national living wage (NLW) rose 6.6% in April 2022 and other, non-NLW, wages will also need to rise to improve the recruitment and retention of staff in a tight labour market. ²⁵⁸ Institute for Government interviews. Other than wages, providers and local authorities now need to spend more to meet rising inflation and costs, such as fuel – be that for travelling between clients ²⁵⁹ Homecare Association, ‘Fuel costs and homecare – impact on service capacity’, 13 April 2022, retrieved 10 May 2022, www.homecareassociation.org.uk/resource/fuel-costs-and-homecare-impact-on-service-capacity.html or for heating care homes – and food. ^{260 Association of Directors of Adult Social Services, Spring Budget Survey 2022, 19 July 2022, p. 19, www.adass.org.uk/media/9390/adass-spring-budget-survey-2022-pdf-final-no-embargo.pdf   261 De Albuquerque Green CE, ‘Exploring the effects of the rise of living costs on small to medium sized care home providers and care professionals’, NIHR Policy Research Unit in Health and Social Care Workforce at King’s College London, 30 March 2022, retrieved 28 September 2022, https://blogs.kcl.ac.uk/socialcareworkforce/2022/03/30/living-costs-and-care-home-providers}

All of these cost pressures are in addition to the extra money that local authorities need to implement the social care reforms that the government announced in 2021. ²⁶² HM Government, Building Back Better: Our plan for health and social care, 7 September 2021, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1015736/Build_Back_Better-_Our_Plan_for_Health_and_So… The government has set aside £3.6bn to support reforms of social care charging, including the cap on care costs, the more generous means test for publicly funded social care and the introduction of the “fair cost of care”* for the three years 2022/23 to 2024/25. ²⁶³ Department of Health and Social Care, ‘Market sustainability and Fair Cost of Care Fund: purpose and conditions 2022 to 2023’, 16 December 2021, retrieved 5 May 2022, www.gov.uk/government/publications/market-sustainability-and-fair-cost-of-care-fund-2022-to-2023/market-sustainability-and-fair-cost-of-care-fund-pur… Yet many doubt these funds will be enough. A report from the County Councils Network estimates that the cost of reforms to social care authorities could be £10bn more than the government’s impact assessment suggested ²⁶⁴ Department of Health and Social Care, ‘Social Care Charging Reform Impact Assessment’, 5 January 2022, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/ file/1044903/adult-social-care-charging-reform-impact-assessment.pdf over the first nine years. ²⁶⁵ Newton and County Council Network, Preparing for Reform: Understanding the impact of adult social care charging reform and planning for successful implementation, 25 May 2022, retrieved 15 August 2022, www.countycouncilsnetwork.org.uk/new-analysis-reveals-the-regional-impact-on-local-councils-of-the-governments-flagship-adult-care-reforms Due to concerns about the cost burden on local authorities, the government decided to delay the implementation of section 18(3) of the Care Act for those already in residential care until April 2025. ²⁶⁶ Keegan G, ‘Social care update’, written statement, UK Parliament, 7 July 2022, retrieved 15 August 2022, https://questions-statements.parliament.uk/written-statements/detail/2022-07-07/hcws189

The spring statement 2022 ²⁶⁷ HM Treasury, Spring Statement 2022, GOV.UK, 23 March 2022, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1062486/Spring_Statement_2022_Web_Accessible.pdf made clear that there would be no additional support for public services beyond what was announced in the 2021 spending review. ²⁶⁸ HM Treasury, Autumn Budget and Spending Review 2021: A stronger economy for the British people, 27 October 2021, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/ file/1043689/Budget_AB2021_Web_Accessible.pdf As discussed in more detail in the Neighbourhood services and Cross-service analysis chapters, it is now unlikely that total local authority funding will be enough to meet increased demand and rising inflation, let alone the implementation of the reform package described above.

Providers are already feeling the dual effects of increasing cost pressures and reduced support from central government (among other factors): 67% of councils reported that care providers had gone out of business or handed contracts back in the six months to March 2022, compared with 25% in the six months to March 2020. ²⁶⁹ Association of Directors of Adult Social Services, Spring Budget Survey 2022, 19 July 2022, p. 21, www.adass.org.uk/media/9369/adass-spring-budget-survey-2022-pdf-final-no-embargo.pdf Local authorities may struggle to continue supporting the market without additional resources from central government.

_{* The FCC is part of the Johnson government’s adult social care reform package announced in September 2021. This measure aims to improve the stability of the social care market after the implementation of section 18(3) of the Care Act 2014, which will end self-funders – those who pay for their own care – having to pay more for care than those whose care is purchased by local authorities on their behalf. Local authorities will meet the shortfall in funding that this will create for providers. They will now pay a ‘fair’ amount for the care they purchase, to cover providers’ costs and allow for some profit. (See Department of Health and Social Care, ‘Market Sustainability and Fair Cost of Care Fund: purpose and conditions 2022 to 2023’, 16 December 2021, retrieved 30 September 2022, www.gov.uk/government/publications/market-sustainability-and-fair-cost-of- care-fund-2022-to-2023/market-sustainability-and-fair-cost-of-care-fund-purpose-and-conditions-2022- to-2023)}

Care worker vacancies fell during the first year of the pandemic, but are now on the rise

During the first year of the pandemic, both the turnover rate and the vacancy rate among social care workers fell, following patterns seen across other public services. But this trend reversed from April 2021 onwards, ²⁷⁰ Skills for Care, ‘Vacancy information – monthly tracking’, Skills for Care, (no date) retrieved 1 August 2022, www.skillsforcare.org.uk/adult-social-care-workforce-data/Workforce-intelligence/publications/Topics/COVID-19/Vacancy-information-monthly-tracking.as… with the annual vacancy rate reaching 10.7% in 2021/22 ²⁷¹ Ibid. – the highest level it has been since the beginning of the Skills for Care time series in 2012/13.

There were 50,000 fewer filled posts in the social care workforce in March 2022 compared with March 2021

The rise in the vacancy rate was the result of people leaving the adult social care workforce. The number of filled posts in the social care workforce decreased by 50,000 between March 2021 and March 2022, from 1.67 million to 1.62 million. ²⁷² Skills for Care, ‘The size and structure of the adult social care workforce in England’, July 2022, retrieved 1 August 2022, www.skillsforcare.org.uk/Adult-Social-Care-Workforce-Data/Workforce-intelligence/publications/national-information/The-size-and-structure-of-the-adul… This included 35,000 fewer carers. This reduction of the workforce has severe implications for the functioning of the service. Having fewer carers restricts the supply of social care, which in turn makes it harder to place people in care.

A range of factors is driving the exodus of the adult social care workforce. First, care workers were under immense pressure during the first two years of the pandemic and many suffered burn-out due to “chronic stress”, ²⁷³ House of Commons Health and Social Care Committee, Workforce Burnout and Resilience in the NHS and Social Care: Second report of session 2021-22 (HC 22), The Stationery Office, 8 June 2021, p. 11, retrieved 28 September 2022, https://committees.parliament.uk/publications/6158/documents/68766/default causing them to leave for less- intense jobs. Second, approximately 7% of the adult social care workforce comes from the EU, ²⁷⁴ Skills for Care, ‘The size and structure of the adult social care workforce in England’, July 2022, retrieved 1 August 2022, www.skillsforcare.org.uk/adult-social-care-workforce-data/Workforce-intelligence/publications/national-information/The-state-of-the-adult-social-care… but Brexit has made it harder for EU citizens to work in the UK. ²⁷⁵ Beech J, Bottery S, Charlesworth A and others, Closing the Gap: Key areas for action on the health and care workforce, The Health Foundation, The King’s Fund and Nuffield Trust, 21 March 2019, p. 117, www.nuffieldtrust.org.uk/files/2019-03/heaj6708-workforce-full-report-web.pdf

Third, social care offers few opportunities for training or progression ²⁷⁶ The Health Foundation, The King’s Fund and Nuffield Trust, ‘The value of investing in social care’, October 2021, www.kingsfund.org.uk/sites/default/files/2021-10/value-investing-social-care-briefing.pdf – factors that encourage people to stay in the sector ²⁷⁷ Institute for Government interview. – in comparison with other careers. Fourth, the government mandated vaccination against Covid for all care home workers from November 2021. ²⁷⁸ Department of Health and Social Care, ‘Coronavirus (COVID-19) vaccination of people working or deployed in care homes: operational guidance’, 1 March 2022, retrieved 5 May 2022, www.gov.uk/government/publications/vaccination-of-people-working-or-deployed-in-care-homes-operational-guidance/coronavirus-covid-19-vaccination-of-p… Unwillingness to be vaccinated was the second most-cited reason among care home staff for leaving the workforce in December 2021. ²⁷⁹ Department of Health and Social Care, ‘Adult social care workforce survey: December 2021 report’, 17 December 2021, retrieved 5 May 2022, www.gov.uk/government/statistics/adult-social-care-workforce-survey-december-2021/adult-social-care-workforce-survey-december-2021-report Finally, carers are paid poorly compared with workers in other sectors. For example, in 2020/21, the median sales and retail assistant earned 21p more per hour on average than the median care worker. ²⁸⁰ Skills for Care, ‘The state of the adult social care sector and workforce in England 2021’, October 2021, p. 20, www.skillsforcare.org.uk/adult-social-care-workforce-data/Workforce-intelligence/documents/State-of-the-adult-social-care-sector/The-State-of-the-Adu… Adult social care also competes for workers with the NHS, ²⁸¹ Institute for Government interview. which often pays health care assistants and porters more than care workers. ²⁸² Migration Advisory Committee, Adult Social Care and Immigration: A report from the Migration Advisory Committee, The Stationery Office, April 2022, p. 9, https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/1071678/E02726219_CP_665_Adult_Social_Care_Report_Web…

This workforce crisis comes in the wake of repeated calls for the government to design and implement a long-term workforce strategy. ^{283 Comptroller and Auditor General, The Adult Social Care Workforce in England, Session 2017–2019, HC 714, National Audit Office, 2018, p. 44, www.nao.org.uk/wp-content/uploads/2018/02/The-adult-social-care-workforce-in-England.pdf   284 Foster D, Adult Social Care Workforce in England, House of Commons Library, 5 September 2022, p. 30, https://researchbriefings.files.parliament.uk/documents/CBP-9615/CBP-9615.pdf   285 Hemmings N, ‘The adult social care workforce: next in the secretary of state’s in-tray or last on the agenda?’, blog, Nuffield Trust, 18 October 2021, retrieved 28 September 2022, www.nuffieldtrust.org.uk/news-item/the-adult-social-care-workforce-next-in-the-secretary-of-state-s-in-tray-or-last-on-the-agenda} The Department of Health and Social Care committed to producing a workforce strategy in 2018, after recommendations from the National Audit Office ²⁸⁶ Comptroller and Auditor General, The Adult Social Care Workforce in England, Session 2017–2019, HC 714, National Audit Office, 2018, p. 44, www.nao.org.uk/wp-content/uploads/2018/02/The-adult-social-care-workforce-in-England.pdf and the House of Commons Committee of Public Accounts, ²⁸⁷ House of Commons Committee of Public Accounts, The Adult Social Care Workforce in England: Thirty-eighth report of session 2017–19 (HC 690), The Stationery Office, 30 April 2018, https://publications.parliament.uk/pa/cm201719/cmselect/cmpubacc/690/690.pdf but failed to do so. ²⁸⁸ Comptroller and Auditor General, The Adult Social Care Market in England, Session 2019–2021, HC 1244, National Audit Office, 2021, p. 10, www.nao.org.uk/wp-content/uploads/2021/03/The-adult-social-care-market-in-England.pdf This means there has been no update to the workforce strategy since 2009. ²⁸⁹ Ibid. During the legislative process for the Health and Care Act 2022, the government rejected an amendment that would have required it to commit to regular forecasts. ^{290 Parliament.UK, Health and Care Bill (HL Bill 71, 2021–22), The Stationery Office, 2022, p. 2, https://publications.parliament.uk/pa/bills/cbill/58-02/0301/210301v2.pdf   291 Murray R, ‘The Health and Care Act 2022: the challenges and opportunities that lie ahead’, blog, The King’s Fund, 3 May 2022, retrieved 28 September 2022, www.kingsfund.org.uk/blog/2022/05/health-and-care-act-2022-challenges-and-opportunities}

Requests for care from working-age adults grew in the first year of the pandemic but those from the older population fell

Despite a growing population aged 65+, the number of requests for care among this age group fell in 2020/21 compared with 2019/20, down to 1.34 million from

1.37 million. There are a few reasons for this. First, the prevalence of Covid in care homes ²⁹² Morcianao M, Stokes J, Kontopantelis E, Hall E and Turner AJ, ‘Excess mortality for care home residents during the first 23 weeks of the COVID-19 pandemic in England: a national cohort study’, BMC Medicine, 2021, vol. 19, no. 71, retrieved 28 September 2022, https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-021-01945-2 and the risk of carers bringing Covid into households, likely discouraged people from seeking residential and home care. ²⁹³ Institute for Government interview. Second, there is evidence that millions more people provided unpaid care during the first year of the pandemic, as people spent more time at home, ²⁹⁴ Carers Week, Carers Week 2020 Research Report: The rise in the number of unpaid carers during the coronavirus (COVID-19) outbreak, 8 June 2020, p. 4, www.carersuk.org/images/CarersWeek2020/CW_2020_Research_Report_WEB.pdf or were unwilling to allow others into their home due to fears about spreading Covid. ²⁹⁵ Office for National Statistics, ‘Coronavirus and the impact on caring’, 9 July 2020, retrieved 14 June 2022, www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/articles/ morepeoplehavebeenhelpingothersoutsidetheirhouseholdthroughthecoronaviruscovid19lockdown/2020-07-09 This may have depressed demand for local- authority-provided care.

In contrast, the number of working-age adults (aged 16–64) requesting care increased between 2019/20 and 2020/21, from 560,350 to 577,765 – a 3.1% increase. From our interviews, it is unclear what drove this increase, but adult social care directors are increasingly concerned about the financial pressure that rising demand for social care from working-age adults will have on spending, due to this group often having more complex and longer-term requirements than the older population (aged 65+). ²⁹⁶ Association of Directors of Adult Social Services, Spring Survey 2021, 14 July 2021, p. 6, www.adass.org.uk/media/8762/adass-spring-survey-report-2021.pdf

The number of people in long-term care declined in the first year of the pandemic

The number of people in long-term care at the end of the year fell from 630,060 in 2019/20 to 616,180 in 2020/21, a 2.2% decline. This decline was not evenly split by care setting. The number of people in community-based care increased by 0.9%, while the number of people in nursing and residential care fell by 12.8% and 8.1% respectively.

High Covid mortality in nursing and residential homes had the dual effect of reducing the number of people in care and likely discouraging people from seeking care in those settings. But the downward trend of people being cared for in nursing and residential settings predates the pandemic. This is due to a combination of government policy – which aims to increase the number of people cared for at home ²⁹⁷ Homes and Communities Agency and Ministry of Housing, Communities and Local Government, ‘2010 to 2015 government policy: housing for older and vulnerable people’, 8 May 2015, retrieved 14 June 2022, www.gov.uk/government/publications/2010-to-2015-government-policy-housing-for-older-and-vulnerable-people/2010-to-2015-government-policy-housing-for-… – and an increase in personal preference for home care among older people. ²⁹⁸ Just Group, Social Care: Coronavirus – can the catastrophe be a catalyst?, 2 June 2020, p. 11, www.justgroupplc.co.uk/~/media/Files/J/JRMS-IR/news-doc/2020/just-care-report-final.pdf

The proportion of people aged 65+ in long-term care continued to fall in the first year of the pandemic

The proportion of the population aged 65+ in local authority-funded long-term care fell in 2020/21, from 5,297 people per 100,000 population to 5,271 – a 0.5% year-on- year fall and a 16.6% decrease since 2014/15.

There are a number of explanations for this longer-term shift. First, today, people aged over 65 generally have less need for social care than people of the same age 15 years ago. ²⁹⁹ Raymond A, Bazeer N, Barclay C, Tallack C and Kelly E, ‘Our ageing population: how ageing affects health and care need in England’, The Health Foundation, December 2021, p. 6, retrieved 28 September 2022, https://health.org.uk/publications/our-ageing-population Second, cuts in central government grants since 2009/10 have forced local authorities to make tough decisions ³⁰⁰ Atkins G and Hoddinott S, Neighbourhood Services Under Strain: How a decade of cuts and rising demand for social care affected local services, Institute for Government, May 2022, www.instituteforgovernment.org.uk/publications/neighbourhood-services and have resulted in many choosing to ration care, which is easier to do for those aged over 65 than for working-age adults, whose needs tend to be greater. ³⁰¹ Institute for Government interviews.

Third, because the means test for publicly funded care has been frozen in cash terms, a smaller proportion of people are eligible for it. ³⁰² Bottery S and Jeffries D, ‘Social care 360: access’, The King’s Fund, 1 March 2022, retrieved 28 September 2022, www.kingsfund.org.uk/publications/social-care-360/access#eligibility Finally, local authorities moved away from being ‘care-package factories’ that offer social care as the first option, ³⁰³ Institute for Government interview. to making greater use of ‘asset-based’ models – such as the ‘three conversations’ model ³⁰⁴ Kirin C, ‘How three conversations have changed the way we do social work’, Community Care, 3 May 2016, retrieved 9 August 2022, www.communitycare.co.uk/2016/05/03/three-conversations-changed-way-social-work – which aim to integrate people into communities by making use of any skills and connections they have. The aim of this approach is to allow people to live fulfilled, independent lives without relying on long-term social care. ³⁰⁵ Social Care Institute for Excellence, ‘An asset-based approach for communities for better joined-up care’, (no date) retrieved 9 August 2022, www.scie.org.uk/integrated-care/better-care/guides/work-together/asset-based-approach

But asset-based approaches may not be fulfilling their purpose, for a couple of reasons. First, it could be that local authorities use these approaches as a means of saving money, in the process pushing caring responsibilities on to families, neighbours and the voluntary sector. ³⁰⁶ Caiels J, Milne A and Beadle-Brown J, ‘Strengths-based approaches in social work and social care: reviewing the evidence’, Journal of Long-Term Care, 2021, pp. 401–22, https://kar.kent.ac.uk/92788/1/Caiels%20et%20al.%20SBA.pdf Second, there is little evidence about whether these approaches deliver better or worse outcomes.

The number of completed short-term care packages fell in the first year of the pandemic

The number of completed short-term care packages to maximise independence (among both new and existing clients) fell from 261,605 in 2019/20 to 246,600 in 2020/21, a 5.7% decline. As with long-term care packages, this could be because people avoided care where possible due to Covid. Another reason may be that it was easier at the height of the pandemic to discharge people from hospital into nursing or residential care, rather than into short-term settings, which can require more specialised care. ³⁰⁷ Institute for Government interview. There is also evidence of staff shortages during the pandemic leading to reablement staff – who usually assist people coming out of hospital to regain the skills that will allow them to live independently – working in residential homes, therefore making it harder for local authorities to place clients in short-term care. ³⁰⁸ Association of Directors of Adult Social Services, ‘ADASS Winter Contingencies Survey’, 13 January 2022, retrieved 18 August 2022, www.adass.org.uk/adass-winter-contingencies-survey

It is also worth noting that if local authorities were pursuing an asset-based approach with the aim of facilitating independent living rather than reducing the amount of budget dedicated to adult social care, then we would expect to see increasing levels of short-term care packages to maximise independence. This outcome is not evident from the data.

There are signs of a backlog in social care demand

The decline in activity in adult social care could mean that there is pent-up demand for this care. There is some indication of this already: the Association of Directors of Adult Social Services (ADASS) estimates that as of April 2022, 294,449 people were awaiting assessment for care, ³⁰⁹ Association of Directors of Adult Social Services, ‘ADASS Survey – adult social care: people waiting for assessments, care or reviews’, 4 August 2022, p. 3, www.adass.org.uk/media/9377/adass-survey-asc-people-waiting-for-assessments-care-or-reviews-publication.pdf up from 70,000 in September 2021, ³¹⁰ Association of Directors of Adult Social Services, Waiting for Care and Support, 13 May 2022, p. 5, www.adass.org.uk/media/9215/adass-survey-waiting-for-care-support-may-2022-final.pdf with 73,792 of those waiting for more than six months. ³¹¹ Association of Directors of Adult Social Services, ‘ADASS Survey – adult social care: people waiting for assessments, care or reviews’, ADASS, 4 August 2022, p. 3, www.adass.org.uk/media/9377/adass-survey-asc-people-waiting-for-assessments-care-or-reviews-publication.pdf Part of the reason for this delay in receiving assessments is that the number of social workers – local authority employees who carry out social care assessments, alongside other responsibilities – declined from 17,500 in 2020 to 17,300 in 2021. ³¹² Skills for Care, ‘Headline social work information’, September 2021, retrieved 25 May 2022, www.skillsforcare.org.uk/adult-social-care-workforce-data/Workforce-intelligence/publications/Topics/Social-work/Headline-social-work-information.aspx While not a large drop (only 1.1%), this does mean that fewer workers are now carrying out a greater volume of work, leading to a bottleneck before people even reach care.

When a social worker assesses a client as being in need of adult social care, often there is no care available for them, due to the workforce ³¹³ Hemmings N, ‘The adult social care workforce: next in the secretary of state’s in-tray or last on the agenda?’, blog, Nuffield Trust, 18 October 2021, retrieved 17 May 2022, www.nuffieldtrust.org.uk/news-item/the-adult-social-care-workforce-next-in-the-secretary-of-state-s-in-tray-or-last-on-the-agenda and cost pressures described above. ³¹⁴ Learner S, ‘Care homes turn away residents as staff shortages worsen’, carehome.co.uk, 13 January 2022, retrieved 17 May 2022, www.carehome.co.uk/news/article.cfm/id/1663313/staff-shortages-care-homes-close This means that people who need care may go without ³¹⁵ Bird N, ‘Carer shortage: Newport woman left without home visits’, BBC News, 28 September 2021, retrieved 17 May 2022, www.bbc.co.uk/news/uk-wales-58720237 or seek care elsewhere, not least from unpaid carers. ³¹⁶ Association of Directors of Adult Social Services, ‘ADASS Survey – adult social care: people waiting for assessments, care or reviews’, ADASS, 4 August 2022, p. 2, www.adass.org.uk/media/9377/adass-survey-asc-people-waiting-for-assessments-care-or-reviews-publication.pdf

The reduction in the number of people in care aged 65+, up to 2019/20, despite an increase in the number of requests for care, means it is likely there was substantial unmet demand even before the pandemic. Unmet demand for social care may increase pressures in primary, community and secondary care, ^{317 Hughes L and Keeble M, ‘Investing in social care to reduce healthcare utilisation’, British Journal of General Practice, 2020, vol. 70, no. 690, pp. 4–5, retrieved 18 May 2022, https://bjgp.org/content/70/690/4   318 The Health Foundation, The King’s Fund and Nuffield Trust, ‘The value of investing in social care’, October 2021, www.kingsfund.org.uk/sites/default/files/2021-10/value-investing-social-care-briefing.pdf} although evidence for this is mixed. ³¹⁹ Seamer P, Brake S, Moore P, Mohammed MA and Wyatt S, ‘Did government spending cuts to social care for older people lead to an increase in emergency hospital admissions? An ecological study, England 2005-2016’, BMJ Open, 2019, vol. 9, no. 4, retrieved 28 September 2022, https://bmjopen.bmj.com/content/9/4/e024577.full It should also be noted that causality between the health and social care systems flows both ways; during the worst of the pandemic, hospitals often discharged patients too early, meaning that they had a higher need for care, putting even more pressure on adult social care. ³²⁰ Association of Directors of Adult Social Services, Spring Budget Survey 2022, 19 July 2022, p. 30, www.adass.org.uk/media/9390/adass-spring-budget-survey-2022-pdf-final-no-embargo.pdf